Trinitas Mobile Integrated Health System Heart Failure Approach: A Model for Chronic Disease Management

Trinitas Regional Medical Center has developed a program focused on prevention of heart failure readmissions using paramedics trained with the skills of community health workers, advanced practice nurses, emergency medical technician trained dispatchers, and physicians. The research is to determine if Emergency Medical Services resources can work on a multidisciplinary integrated care team to intervene on patients post-discharge with patient education and non-emergent interventions resulting in reduced 30-day readmissions. The researchers performed a descriptive study to explore the hypothesis through retrospective data review. The program participants were compared to a randomly chosen sample from the same geographic area with the same diagnosis. Of the 43 patients in the Mobile Integrated Health Service (MIHS) program, three were readmitted for any cause within 30 days post-discharge from index admission for a rate of 6.9%. The readmission rate for a random control sample of 48 patients failure was 22.9% (n=11/48). The program sample was compared to the control sample using an independent t-test (95% CI, two-tailed p-value of .0316). The research supports the hypothesis that paramedic resources can work on a multidisciplinary integrated care team to intervene on patients post-discharge with patient education and non-emergent interventions.

Author(s):

Joseph L. McTernan, Gerard Muench, Raffee Matossian, Lucy Ankrah, Mary McTigue, Brant Maslowski, Elizabeth Parisik

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